Right Ventricular Outflow Tract Reconstruction as First Stage Palliation for VSD/PA
*Luke M Wiggins1, *Kristopher Kallin2, *Winfield Wells2, *Vaughn Starnes2, *S. Ram Kumar2
1University of Southern California, Los angeles, CA;2Children's Hospital Los Angeles, Los angeles, CA
OBJECTIVES: Neonatal palliation followed by later complete repair is still a widely practiced option in the management of ventricular septal defect with pulmonary atresia and confluent branch pulmonary arteries (VSD/PA). Systemic to pulmonary shunting is the most commonly used palliative strategy. We have used transannular right ventricular outflow tract (RVOT) patch reconstruction as initial palliation with the expectation that this would result in reliable growth of the RVOT, and symmetric growth of branch pulmonary arteries. We sought to compare the outcomes of modified Blalock-Taussig shunt (mBTS) versus RVOT reconstruction as initial palliation for VSD/PA.
METHODS:We retrospectively reviewed the charts of 45 patients who underwent neonatal palliation for VSD/PA or DORV/PA during the last 10 years at our institution . Hospital outcomes as well as timing and technique of complete repair were evaluated.
RESULTS: 32 patients underwent initial palliation with mBTS and 26 (81%) have subsequently undergone complete repair at a median time interval of 9.8 months. 13 patients underwent initial palliation with RVOT patch reconstruction of which 11 (85%) have gone on to complete repair at a median of 7.5 months. Post-operative length of stay was a median of 22 days (8-38) for RVOT patch and 13 days (8-18) for mBTS. There was no 30 day mortality for RVOT patch palliation and 9% 30 day mortality for mBTS. 19 patients palliated with mBTS had preoperative imaging prior to complete repair and were found to have a mean Nakata index of 155mm2/m2+19. 8 patients who underwent palliation with RVOT patch also had preoperative imaging performed which revealed a mean Nakata index of 205mm2/m2+79. All of the 26 (100%) patients who underwent complete repair following modified BTS required conduits in the RVOT. Of the 11 patients who underwent complete repair following RVOT patch 1 (9%) required a conduit and others (91%) had transannular patch.
CONCLUSIONS: Transannular RVOT augmentation is a viable first stage palliation for VSD/PA with confluent PA. This results in reliable growth of RVOT, avoiding the need for homograft use at the time of complete repair.
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